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endocrinology finals Flashcards

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USMLE® Step 1 flashcards
1
Q

What are the 4 Diagnostic criteria for DM?

A
  1. H1C >= 6.5%
  2. fasting glucose >= 126
  3. glucose 2h after loading dose >= 200
  4. glucose >=200 in rendom test + glucose symptoms

  • serum glucose need to be confirm with another test in a different day
  • dont check during stress / ilness
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2
Q

What is the A1C target in DM
and what is the glucose level target

A
  1. A1C < 7% (under 6% found to be danger in high risk CV pt)
  2. Glucose level- between 70-180 (fasting glucose 70-130, 2h after meal 180)
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3
Q

3 main side effect of metformin

A
  1. Lactic acidosis (metabolic acidosis)&raquo_space; need to reduce dose in CKD
  2. B12 def.
  3. GI upset- neuasa, vomiting, diarrhea

Weight loss

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4
Q

C/I for mteformin

A
  1. kisney failure (GFR < 30)
  2. HF
  3. Lung failure
  4. other organs failure
  5. Systemic ilness or shock
  6. during IV contrast imaging / major surgery and 48 hrs later
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5
Q

Which DM medications can casue hypoglycemia

A
  • Sulfanulurea
  • Glinides
  • insulin
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6
Q

C/I for glucosidase inhibitors + sulfanylurea + Glinides

A

Renal /liver insuff.

Exp. repglinides- clearne only from liver

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7
Q

GLP-1 side effects

A

pancreatitis

Execpt- Exenatide

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8
Q

DDP-4 inhibitors side effect

gliptins

A

increase risk for Nasopharyngitis and URTI

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9
Q

Which diseases are C/I for the use of GLP-1

A

MEN
or
Medullary thyroid carcinoma

Can increase the prevalnce of Medullary thyroid carcinoma

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10
Q

Which DM medication can asue Urticaria / angioedema and immune mediated dermatological effect

A

DDP4inhibitors

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11
Q

nall of the following are cheracteristics of the DM medication——

Amylin analog, can be use in DM type I and II, loss weight, reduce hyperglycemia after food

A

Pramlinitide

may cause after meal (postprandial hypoglycemia)

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12
Q

which DM medication is beneficial in Pt with Renal disease

A

Thiazolidinediones

Gliterzone suffix

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13
Q

What is the C/I for Thiazolidinediones

A
  1. NYHA III-IV HF

may exacerbate CHF

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14
Q

What are possible Side effect using Thiazolidinediones

A
  1. Reduce bone density
  2. Weight gain
  3. excacerbate CHF
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15
Q

what is the MOA of alpha-glucosidase inhibitors?

Acrebose

A

inhibition of absorbtion of glucose by the intestine

combine with drugs like sulfnyl- can cause hypoglycemia

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16
Q

True or false?

SGLT2i lower episodes of CV event and reccurent hospitalization of CHF

A

TRUE

also reduce risk for diabetic nephropathy

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17
Q

Which DM drug can increase the risk for Euglycemic DKA

A

SGLT2i

glucose < 200

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18
Q

C/I for SGLT2i

A

Renal insuff. (not strat if GFR < 45, no use at all if GFR < 30)

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19
Q

Which DM medication does not effect at all on weight?

A

DPP4i

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20
Q

Which DM medication can be given in hepatic failure?

A

Intecrines (GLP-1, DPP4i), SGLT2i

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21
Q

Which DM medication can not be given in HF?

A

Metformin
TZD (Gliterzone)

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22
Q

How to confirm DKA Dx?

A
  • hyperglycemia
  • Eleveted Serum beta-hydrocybutarate
  • Metabolic acidosis
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23
Q

What is the first Tx of DKA?

A

Fluid replacement:
2-3 L of normal seline or Ringers over first 1-3h

when blood glucose reach to 250 change to 5% glucose and 0.45% seline (prevent hyperchloremic acidodsis)

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24
Q

How to start insulin in DKA, and when to halt the Tx in insulin

A

insulin- 0.1 units/Kg per hour (increase 2-3 folds if no response after 2-4h)

halt when K levels < 3.3- od not administer insulin until pottasium is corrected

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25
Q

Which electrolyte disbalance DKA tx can cause?

A

all the Hypo:
* K
* Mg
* P

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26
Q

In which levels of Potassium in DKA a K will be added to the infusion?

A

K < 5-5.2

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27
Q

When we will Treat with HCO3 in DKA?

A

**only in Exterme acidosis PH < 7 **

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28
Q

What is the main Tx for HHS?

A

Fluid replacment

החזרת נפח נוזלים

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29
Q

True or false?

יש קשר סיבתי ברור בין היפרגליקמיה כרונית להיווצרות סיבוכים מאקרווסקולרים?

A

False
הקשר הסיבתי בהיפרגליקמיה היא עם סיבוכים מיקרווסקולרים ולא מאקרו

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30
Q

Which vaccination are recommended to all DM pt?

A

Influenza
Covid
Pneumoccoc

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31
Q

Whats the target in DM pt regarding their:
LDL , HDL levels
TG
BP

A

LDL < 100, < 70- if CHF or 2 CV risk
HDL ~40-50
TG < 150
BP- like general population (140/90) if theres CV risk (130/80)

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32
Q

What is the most common reason for ESRD in the develop world

A

Diabetic nephropathy

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33
Q

DM

How many DM pt will develop nephropathy?

and what is the % correlation between nepropthy to retinopathy

A

20%-40% will develop nephropathy

correlation:
DM1- 90%
DM2- 60%

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34
Q

What is a major risk factor for developing Diabetic nephropathy?

A

microalbuminurea (30-300)
50% of them will develop macroalbuminurea (>300)
50% of them will progress to CKD to ESRD

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35
Q

What is the first Tx when DM pt present with albuminurea?

A

ACEi / ARBS
if C/I then :
diuretics, CCB (non-dhydro = Verpamil/ dilitazem) or BB

if persist:
MRA

DM2&raquo_space; SGLT2i

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36
Q

Reccurent episodes of hypoglycemic events in DM pt can lead to———

A

Hypoglycemia associated autonomic failure

damage the counter regulation of glucose (less glucagon when hypo, and less epinephrine)

decrease in awarness to hypo event

can be reverseble if hypo is prevent for 2-3 weeks

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37
Q

What is the cumaltive risk for pregnent women with gastetional Diabetic to develop DM?

A

risk of 60% in the following 10-20 years

screening recommended every 3 yrs for womens after Gs .diabetic

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38
Q

What is the most common reason for Cushing syndrome?

A

Steroid therapy

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39
Q

whats the different between Cushing disease to syndrome

A

Cushing disease is a sub-type of cushing syndrome where theres acess ACTH release from a pituatery adenoma

most common Endogenous reason for cushing

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40
Q

Which test can be done to check if cushing is ACTH-dependent vs. independent.

and what will be the further test based on the reasults

A

Check for ACTH levels

High/ normal ACTH- dependent&raquo_space; Hypopyseal MRI
Low ACTH- independent&raquo_space; Adrenals CT

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41
Q

How many of the tumors are being missed by MRI of the adrenals?

A

40%

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42
Q

which test could diff. between pituatery adenoma to Ectopic ACTH (like SCLC)

A

High dose Dexamethasome test (8mg)

if ACTH supress&raquo_space; Adenoma
If ACTH remain High&raquo_space; Ectopic source

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43
Q

What is the main reasons for Hyperaldo?

A
  • primary hyperaldo:
  • 60% Bilateral micronodular hyperplasia
  • 40% Conn’s syndrome (unilateral adenoma)

also rare- Glucocorticoid-remediable hyperaldo- regulate system on aldosterone is by ACTH and not RASS

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44
Q

Which medication should be stop before performing Aldo-renin ratio test?

A
  1. Aldactone - after 4 wks w/o
  2. correction of hypokalemia
  3. consider- stopping beta-blockers for 2 wks (may cause FP)
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45
Q

What is the tests preform in suspicion of hyper-aldo?

A
  1. Aldo-renin ratio
  2. confirmation test- supress test by seline ingusion/ oral Na loading, fludrocortisone suppresion
  3. non Contract CT of adrenals
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46
Q

Which medication are elevate and which depress the ratio between Aldo-renin

A

Beta-blocker- elevate ratio

ACEi + ARB’s- decrease ratio

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47
Q

Which workup is rq after incedintiloma > 1 cm?

A

Encodrine workup include:
1. Metanephrins
2. screening for kushing (1st test Dexamethasone test)
3. Renin aldosterone ratio- if HTN present
4. Sex hormones if lesion > 4 cm

sex hormones: 17-hydroxyprogesterone, andriostenedione, DHEAS

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48
Q

When we will operate icidentally discovered adrenal mass

A

Hormonal activity
Malignancy

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49
Q

what are the 2 finding in imaging that have high suspicion for adrenal malignancy?

A
  1. size > 4 cm
  2. Density > 20 HU
50
Q

What are the main Cherecters of primary adrenal insuff.

Think about which hormones will be defficient

A
  1. Hyperpigmentation- high levels of ACTH
  2. Aldosterone def.- acidosis, hyperkalemia, salt wasting type (hyponathremia) + hypovolemia
  3. Cortisol def.- Weight loss, fatigue, GI symptoms, hypoglycemia, postural hypotension

problem producing Aldo + Cortisol

51
Q

What is the most common primary and secondary adrenal insuff

A

primary- Addison (autoimmune disease)
Secondary- Steroid medications

52
Q

Which melanoma medication can cause Secondary Adrenal insuff

A

Anti-CTLA4 (ipilimumab)

causes hypopyseal autoimmune disease

53
Q

How we diagnose adrenal insuff. ?

until the step of primary vs secondary

whats the steps in the algorithm

A
  1. Sinacten test (ACTH analog)- if Adrenal insuff. present > 4 wks cortisol will not elevate.
  2. Determine if primary or secondary- plama ACTH, Renin aldosterone ratio

Always Check for TSH- hypothyroidism can be a reason for hypoaldo

54
Q

what is the famous triad of pheochromocytoma

A

Palpitation
headache
sweating

55
Q

During surgery of pheochromocytome
how do we stabilize BP?
when it drop or elevated?

A

elevated- Nitroprussid
Drop- fluids IV

56
Q

what is the most coomon reason for Thyrotoxicosis

A

Grave’s disease

57
Q

Which Ab can be found in Grave’s disease

A

Thyroid stimulation immunoglobulins (TSI)

also called TRAb (TSH receptor Ab)

58
Q

Which other Ab can be found in graves , which will not cause a disease

A

anti-TPO
anti- TG

59
Q

all the following can lead to a high suspicious of ————- disease

Pre-tibial edema, purple -red plaques
exophtalmus

A

Grave’s disease

60
Q

Which severe side effect can Mathimazole and PTU can cause

A

Vasculitis
Agrnulocytosis

61
Q

How much time after Tx with Anti-thytoid medication we will see remission in Grave’s disease

A

12-18 months for max remission

62
Q

What are the main indications for PTU and why?

A
  1. 1st trimester of pregnanct
  2. thyroid storm
  3. can’t tolerate mathmizole

Beacute PTU is heptotoxicity

63
Q

What is the general stages when Tx in reactive Iodine (I131) is preform?

A
  1. start anti-thyroid Tx for a month
  2. few days begore ablation Tx stop medication
  3. procced with iodine reactive therapy
64
Q

Which Biologic Tx is indicated for opthalmology by thyrotoxicosis

A

Teprotumumab
for proptosis, diplopia, functioning

65
Q

Whats the Tx for Thyroid storm

A

ICU
high dose of PTU, KI, proprenolol

sometimes add Hydrocortisone

66
Q

What are the reasons for sub-acute thyroiditis?

A
  1. viral(or granulamtous) - influenza, covid, adenovirus
  2. Silent - including postpartum
  3. Mycobacterial inf.
  4. drug induce- amiodarone, interferone
67
Q

which tyroid condition is present with large and pain thyroid gland?

A

Subacute Thyroiditis

68
Q

What will be the ratio of T4/T3 + ESR in sub-acute thyroiditis

A

high ratio T4/T3
+
Eleveted ESR and < 5% of radioactive iodine

69
Q

Tx for sub-acute thyroiditis?

A
  1. Aspirin/ NSAIDS
    second line
    Steroids for 6-8 wks
70
Q

Which Ab will be present in postpartum thyoridits
+
ESR levels
+
size and painful/ non painful gland

A
  1. anti TPO
  2. low ESR (sub-acute = high)
  3. painless / silent
71
Q

when amiodarone will cause hypothyroidisem

A

if theres an autoimmune disease of hypo (in base) like hasimoto- then there will be no escape from the wolf chaikoff affect

will not stop Amiodarone, just add levothyroxine

72
Q

What are the 2 main types of amiodarone induces thyrotoxicosis?

and whats the main diff. bewteen them

A

Type I (AIT)- pt wth pre-disposition for thyroid disease ( Grave’s / MNG)&raquo_space; more iodine will lead to more thyroid hormones
Type II- no pre-disposition. destructive thtrotoxicosis

73
Q

How to diff. between AIT type I and II

and whatsthe Tx?

A

colour doppler

High vasculativity&raquo_space; Type I

**stop amiodarone **

  1. Type I Tx- High dose Anti-thyorid + K-percholate (can cause Agranulocytosis)
  2. Type II Tx- prednisone + lithum&raquo_space; Thyrodectomy (most effective long term )
74
Q

What will be the following levels in Factitious thyrotoxicosis?

Tg (thyroglobulin)
T4
TSH

A

low Tg
low TSH
high T4

קליטה נמוכה בבדיקת יוד

75
Q

Whats the Tx of choice for Toxic thyroid adenoma

A

יוד רדיואקטיבי- מצטבר באדנומה (טיפול דפיניטיבי)

76
Q

What is the DDx for
low T3 (with T4 + TSH normal)

A

high rT3- Euthyroid sick syndrome
low rT3- central hypothyroidisem

77
Q

When we will Treat Sub-clinical Hypothyroidism
(high TSH, normal T4, asymptomatic)

A
  1. TSH > 10 + anti-TPO
  2. pregnancy or planning pregnancy
  3. heart disease

if we not treat- follow up 1X year

78
Q

Euthyroid sick syndrome

Tx?

A

Monitoring

79
Q

What is Myxedema coma?
% of death?
prevelance age?

A

Acute and exterme hypothyroiditis

  • 20-40% dath
  • most common in elderly
80
Q

Tx of myxedema coma

A
  • LT4 IV
  • consider adding T3 for inital Tx
  • Hydrocortisone
  • heating when Tm < 30
  • Treat the Triger!!
81
Q

What are the indication of radioactive iodine ablation

A

Toxciv adenoma
MNG
Graves
adv. carcinomas

always treat before with anti-thyroid medication and stop few days prior the procedure

82
Q

Thyroid tumors

Whats the Tx for tumors > 4 cm

A

near total thyroidectomy + ablation by radioactive iodine

83
Q

Which marker is used to asses residual disease or reccurent of thyroid cancer? (after total thyroidectomy and ablation)

A

Thyroglobulin

+
Neck US for LN 6 month after ablation

most reccurence will be at cervical LN

84
Q

Which elecctrolyte disturbance Def. in Vitamin D can cause?

A

Hypocalcemia
Hypophosphatemia
Hypomagnesemia

85
Q

איזה סוג של שומן משקף היקף המותניים?

והיכן נמדד

A

שומן ויסצרלי
measure above the iliac crest (less reliable then MRI/CT)

86
Q

What is the definition of metabolic syndrome

A

at least 3 of the following
1. היקף מותניים- גברים > 102, נשים > 88 ס”מ
2. TG > 150
3. HDL- גברים < 40, נשים < 50
4. BP > = 130/85
5. Fasting glucose >= 100 / present of DM

87
Q

What is the indication for briatric surgery?

A

BMI >= 35 + risk factors
BMI >= 40

Goal- reduction in 10-8% in 6 months

88
Q

Definition of Osteoporosis

and what is the main clinical presentation

A

Definition
T score <= -2.5

main clinical presentation
vertebral and hip fractures

T- score- ביחס לממוצע מבוגרים בריאים צעירים מאותו מין ומוצא

89
Q

True / false

PPI increase the risk for osteoporosis

A

True

also: steroids, Cyclosporins, anti-epileptic, aromatase inhibitors, SSRI, lithum, TZD

90
Q

Who will be check for bone density?

A
  1. every women > 65 , post-menopausal, during menopausal
  2. every males > 70 or 50-69 with clinical risk for fracture
  3. fracture in age 50
  4. מבוגרים על מחלות רקע שנוטלים תרופות המקושרות למסת עצם נמוכה (למשל פרדניזון 3 חודשים)
91
Q

Which supplaments and medications will be given to a pt with osteoporosis?

A
  1. calcium- 1000 mg < 50 > 1200 mg.
  2. Vitamin D- 1000-2000IU

**only ** Vitamin D + Calcium toghther will reduce the risk for fractures

Calcium alone can reduce the risk for fracture but in a lesser extent then when combined with vitamin D

92
Q

What is the recommendation of vitamin D supplementation?

A

general population with < 20 - 200IU < age 50 > 400 < 70 > 600IU

93
Q

What is the main indication (and when we should consider also) Pharmacological Tx in osteoporosis and osteoporosis related conditions

A

main indication- fracture from minor trauma + low bone density T < -1
also consider when
1. Osteoporosis (T < -2.5)
2. post-menopausal with fracture
3. risk > 20% for major fracture and > 3% for hip fracture in 10 years

94
Q

Which medication from the antiresoptive agents are approved for osteoporosis/ reduce risk fracture?

5 agents

antiresoptive agents- prevent bone reabsorption

A
  • Astrogen
  • SERM ( Raloxifen- also breast cancer)
  • Bi-phosphonate (Dronate suffix)
  • Denosumab
  • Calcitonin
95
Q

Which medication from the anabolic agents are approved for osteoporosis/ reduce risk fracture?

A

PTH analoges

96
Q

osteoporosis

which womens will take Astogens and which SERMS

what is the reduction risk in fracture?

A

Astorgens- women who start early after entering menopause, Fructure reduction in 50%, a bit elevation in bone mass

SERM- Rloxifene, for womens post-memopausal < 70 age (risk for DVT and storke in older) reduction in cervical vertebra 30-50%

97
Q

Which medication is the mainstream in osteoporosis Tx?

What is C/I
main prons
posibble side effect

A

Bi-phosphonates (Dronate suffix)
C/I - GFR < 35
main prons- reduce incidence of fractures (incluse cervical and hip)
Side effect- Esophagitis, Osteonecrosis of jaw, skin infection, hypocalcemia, atipical fracture of femur

98
Q

What is the MOA of Denosumab

A

Ab inhibit RANKL on osteoclasts

S.E- osteonecrosis of jaw, hypocalcemia and skin inf.

99
Q

What is Teriparatide

A

analog for PTH

the leters:
PARATIDE like para-thyroid

100
Q

Which type of bone trabecular / cortical is damage more in osteoporosis secondary to steroid therapy?

A

Trabecular

101
Q

Osteoporosis secondary to steroids therapy

True or false:
1. osteoporosis is mainly when steroids are given IV
2. below 20 mg a day showed reduce risk
3. women and elderly are at higher risk

A
  1. false- can happen in any form of administration
  2. false- there’s no safe dosage, neither day in day out help.
  3. true
102
Q

How does steroids affect the bones

A

inhibit osteoblasts
more bone reabsopbation, less Ca is reabsorb in the intestine, low sex hormones production in gonads and adrenal

103
Q

What is the changes seen in electrolytes in bone in the abscent of Vitamin D?

A
  1. Hypocaclemia
  2. Hypomagnesemia
  3. hypophosphatemia
  4. elevate ALKP
  5. Proximal myopathy
  6. Osteopenia
104
Q

How does high phosphor levels will affect:
PTH
FGF23
1,25-vit D

A

PTH- elevate = more phosphor will secrete by the kidney’s
FGF23- elevate = secrete phsphore in urine and low secrete of active vit-D
1,25 D- decrease = by FGF23 + High phosphor

Phosphor is secreted in PCT (part of fanconi syn.)

105
Q

What are the 5 main mechanisms of low phosphor

A
  1. Decrese absorbtion in kideny- PTHrP, hyperPTH (primary), hypomagnesemia, alcholoism, high dose steroids
  2. Decrease absorbtion in the intestine
  3. Cell shift (similar to K)- Refeeding synd- hypo K, Po, Mg , B1, insulin Tx in DKA pt, fast prolifration of cells , Gram negetive sepsis
  4. Fast bone production- after para-thyroidectomy, osteoblast metastasis
  5. tumor induce osteomalacia- tumors that secrete FGF23
106
Q

Which severe effect can hypophosphatemia can cause if happend rapidly

A

Rhabdomyolysis
Respiratory failure
Hemolysis

107
Q

Tx for Hypophoshatemia for:
Severe < 2
mild

A

severe < 2
Phosphor IV , must correct Ca level prior
C/I- low Ca levels (Po will bind Ca and worsen hypocalcemia

Mild- Phosphor PO

108
Q

What are the main causes of hyperphosphatemia?

A
  1. impaired renal excretion- hypo PTH or renal insufficeny
  2. Para-thyroid supression (like sarcoidosis (hypercalcemia)
  3. TLS, rhabdomyolysis…
109
Q

What is the main cause of hyper Mg?

A

Renal insuff.

also:
GI loss - diarrhea
Pancreatitis
Renal losses- loop + thizide diuretics
Alchol abuse
Omeprazole - PPI
Foscarnet- anti-viral
Hyperaldostronism

similar to Ca- in bone, similar to K- in cell shift and kidney

110
Q

Hypomagnesemia can lead to which Electrolyte abnormalitiy

A

low Mg:
PTH release &raquo_space; raise mg to normal
very low Mg:
inhibit PTH release&raquo_space; hypocalcemia

hypokalemia- Mg inhibit ROMK excretion (collecting duct)
K wont be corrected until Mg be corrected

111
Q

What is the most common cause of hypercalcemia?

A

hyper PTH
malignancy

in 90% of cases

112
Q

What is the cause of familial hypocalciuric hypercalcemia

A

AD, mut in CaSR - does not sense Ca&raquo_space; PTH elevetion&raquo_space; active vit. D elevation&raquo_space; more Ca absorbation.

High plasma Ca + low urine Ca

mostly mild and a-symptomatic

113
Q

Which malignancy can secrete PTHrP

and what is the most prognostic factor for hypercalcemia

A

Lung SCC
RCC

המנבא העיקרי הינו סוג הגידול ופחות התפשטותו לעצמות

114
Q

how Lithum affect the Ca levels?

A

inhibit the sensetivity of Para-thyroid for Ca = elevete PTH + Hypercalcemia

(like FHH)

115
Q

Hypercalcemia mnemonics

A

Stones, Bones, Groans (GI- anorexia, constipation, peptic ulcers, nausa) and psychiatrc tones

116
Q

how hypercalcemia will be seen on ECG

A

short QT
+
elevetion in ST in V1-V3

117
Q

Tx for hypercalcemia:
Ca < 12
Ca 13-15
Ca > 15

A
  • Ca < 12- Hydration
  • Ca 13-15- agressive hydration + consider other treatments
  • Ca > 15- first 0.9% Hydration until normelize volumic status&raquo_space; after fusid+ consider bi-phosphonates

also consider- Calictonin
Dialysis- in extereme pt.
Steroids- malignancy, excess vitamin D, sarcoidosis

118
Q

Most common cause of primary Hyper PTH

A

isolated adenoma in para-thyroid

(6-10% of cases can be extra-thyroid)

eleveted Ca, PTH, decrease phosphor

119
Q

What are the 7 indication for surgery in a-symptomatic pt with primary hyper-para thyroid

Think: Renal, Skeletal, Age

A

Renal
* Ca levels > 1 of NUL
* Creatinit Clearence < 60
* Ca in urine > 400 mg/day
* nephrolitiasis /nephrocalcinosis
Skeletal
* Bone density T-score < -2.5
* vertebra fractue
Age
* Age < 50

120
Q

What is the first step in Hypocalcemic pt?
and why we do it

A

**Repair Calcium levels by albumin **
added calcium = 0.8 X (1 gram of albumin under 4)

do it to rule out psuedohypocalcemia

121
Q

How chronic hypocalcemia will effect digoxin?

A

Decrease effectivness

122
Q

Which are the 2 situation when theres Hypocalcemia + hypophosphpira

A

Vit. D deff.
+
Hypomagnesemia

USMLE HY notes (34 decks)

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